Cms-p-0015a Mcbs

Statement Charge Series (STQ)
Variable Name

MHMOSTMT

MR Screen Name
BOX STBEG

Question type
routing

ST1

code one

Question text/description
IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN WITHOUT RX COVERAGE ANYTIME DURING
THE CURRENT ROUND) OR (SP WAS COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND)) AND (SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION DRUG PLAN ANYTIME
DURING THE CURRENT ROUND), GO TO ST1 - MHMOSTMT.
ELSE GO TO ST2 - MCSAVAIL.
Now that we have finished talking about medical visits and prescribed medicines, let’s talk about
[your/(SP’s)] medical costs. We should start by looking at any paperwork or written explanations of what
was paid by Medicare, any insurance company, or TRICARE.

Code List

(01) ALWAYS
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
[Do you/Does (SP)] usually receive any statements or papers from Medicare, insurance, such as (MANAGED (-9) REFUSED
CARE PLAN NAME), or TRICARE that show the charges for medical visits or equipment?/Last time, we
recorded that [you/(SP)] (always/sometimes/never) received statements or papers from Medicare,
insurance, or TRICARE that show the charges for medical visits or equipment.]
Please tell me if (currently) [you always receive statements, sometimes receive statements, or never receive
statements/(SP) always receives statements, sometimes receives statements, or never receives
statements].

MCSAVAIL

ST2

yes/no

[Now that we have finished talking about medical visits and prescribed medicines, let’s talk about
[your/(SP’s)] medical costs. We should start by looking at any paperwork or written explanations of what
costs were paid by Medicare, any insurance company, or TRICARE.]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[PROBE IF NECESSARY: Do you have any statements or paper from Medicare, insurance, or TRICARE [that
[you/(SP)] received since the last interview]? (Please include any statements received about [your/(SP's)]
prescription drug benefit.)]
STHIREP

ST3

no entry
BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE SECTION FOR RECENT ROUNDS, THE
PLAN(S) LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU MIGHT EXPECT TO FIND FOR THIS SP.

MATCHST

ST4

no entry

[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE PRESCRIPTION BENEFIT STATEMENTS BY
PROVIDER AND DATE OF SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT (STATEMENT/BUNDLE).]

ST_CHARGEBUNDLE

ST5

roster

STTYPE

ST5AA

code one

ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT) BUNDLE OF EVENTS.
ADD ONE CHARGE BUNDLE AT THIS ROSTER.
SELECT SOURCE OF THE STATEMENT(S) FOR THIS CHARGE BUNDLE

MCARTYPE

ST5AAA

code one

WHICH TYPE OF MEDICARE STATEMENT DO YOU HAVE TO ENTER? [SEE REFERENCE CARDS FOR MEDICARE
STATEMENT EXAMPLES]

BOX ST5A

routing

IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE.
ELSE GO TO BOX ST5B.

(01) MEDICARE SUMMARY NOTICE (MSN) ONLY
(02) INSURANCE STATEMENT ONLY
(03) BOTH MEDICARE SUMMARY NOTICE (MSN) AND
INSURNACE STATEMENT
(04) TRICARE STATEMENT ONLY
(05) BOTH MEDICARE SUMMARY NOTICE (MSN) AND
TRICARE STATEMENTS
(06) BOTH TRICARE AND INSURNACE STATEMENTS
(07) MEDICARE SUMMARY NOTICE (MSN) AND TRICARE AND
INSURANCE STATEMENTS
(08) MPDP STATEMENT OR MA/TRICARE PRESCIRPTION
DRUG BUNDLE
(01) MEDICARE SUMMARY NOTICE: PART B MEDICAL
INSURANCE - ASSIGNED OR UNASSIGNED (EXAMPLE 1)
(02) MEDICARE SUMMARY NOTICE: PART B MEDICAL
INSURNACE OUTPATIENT FACILITY CLAIMS (EXAMPLE 2)
(03) MEDICARE SUMMARY NOTICE: PART A HOSPITAL
INSURANCE INPATIENT CLAIMS (EXAMPLE 3)
(04) MEDICARE SUMMARY NOTICE: HOME HEALTH CARE
CLAIMS (EXAMPLE 4)
(05) MEDICARE SUMMARY NOTICE: PART A HOSPICE
FACILITY CLAIMS (EXAMPLE 5)

Statement Charge Series (STQ)
Variable Name
PDPTYPE

MSNCLNUM

MR Screen Name
ST5A

Question type
code one

Question text/description
SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR THIS BUNDLE.

BOX ST5B

routing

BOX ST5

routing

ST7

text

SET STATEMENT TYPE.
GO TO BOX ST5.
IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance, 5/MedicareAndTricare, OR
7/MedicareAndTricareAndInsurance, GO TO ST7 - MSNCLNUM.
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance, GO TO ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST11B - PDPBEGMM.
ENTER UP TO FIVE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE (MSN)
ASSOCIATED WITH ONE CLAIM TOTAL.

Code List
(01) MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT
(02) MEDICARE ADVANTAGE STATEMENT
(03) TRICARE STATEMENT

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

IF NO CLAIM CONTROL NUMBER(S) LISTED, ENTER "DON'T KNOW".
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN COMMENTS.
MSNCLNM2

ST7

text

MSNCLNM3

ST7

text

MSNCLNM4

ST7

text

MSNCLNM5

ST7

text

BOX ST7

routing

ST8

text

BOX ST8

routing

ST9

code one

MSCLVER1

WHICHNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
IF ST7 - MSNCLNUM = DK, GO TO BOX ST9.
ELSE GO TO ST8 - MSCLVER1.
PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN)
AGAIN.
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE (MSN)
DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)

(01) CONTINUOUS ANSWER
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX
ST9.
ELSE GO TO ST9 - WHICHNUM.
(01) FIRST
(02) SECOND
(03) NEITHER

SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)

NEWCLNUM

ST9

text

BOX ST9

routing

ST10

text

BOX ST10

routing

TRICLNUM

ST11

text

PDPBEGMM

ST11B

date

PDPBEGDD

ST11B

date

INSCLNUM

WHICH IS CORRECT?
ENTER CORRECT MSN CLAIM CONTROL NUMBER:

IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST10 INSCLNUM.
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. IF NO CLAIM CONTROL
NUMBER LISTED, ENTER "DON'T KNOW".
IF TYPE OF STATEMENT = 6/TricareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST11 TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE STATEMENT. IF NO CLAIM CONTROL NUMBER
LISTED, ENTER "DON'T KNOW".
ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE PRESCRIPTION DRUG BENEFIT
STATEMENT.
BEGINNING DATE:

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
PDPBEGYY

MR Screen Name
ST11B

Question type
date

Question text/description

PDPENDMM

ST11B

date

ENDING DATE:

PDPENDDD

ST11B

date

PDPENDYY

ST11B

date

INCTYPE

ST12

code all

WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT)?
CHECK ALL THAT APPLY.

BOX ST12

routing

ST13

roster

IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO ST13 - PROVIDER_STDATE.
ELSE GO TO BOX ST26.
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

PROVIDER_STDATE

PROVNAME

ST13

verbatim

Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
ALL PROVIDERS WHERE PROVNUM>02.

[PROVIDER LOOKUP CAN BE CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

GROUPNAM
STDATEUPD

ST13
ST14

VISITYPE

verbatim
code one

NAME:
GROUP:
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?

select one

SELECT TYPE OF VISIT TO ADD:

EVENT_STDATEDIT

ST15

roster

EVENT

ST16

roster

(01) NO, DO NOT NEED TO ADD OR EDIT EVENT DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(10) All other visits to Medical Provider (MP)
(01) CONTINUOUS ANSWER

SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from (01) CONTINUOUS ANSWER
(HOSPITAL NAME)?] Please tell me all the dates [since (REFERENCE DATE/UTILDATE)/between (REFERENCE (-8) DON'T KNOW
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
(-9) REFUSED
ENTER ALL DATES.
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
[IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.]

Statement Charge Series (STQ)
Variable Name

MR Screen Name
BOX ST16A

Question type
routing

BOX ST16B

routing

ST17

no entry

BOX ST17

routing

PROVSPEC

ST18

code one

PROVSPOS
PROVSPEC

ST18
ST18A

text
code one

STDATEINTRO

Question text/description
Code List
IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO BOX
ST16B.
ELSE GO TO ST14 - STDATEUPD.
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'IP', 'OP', OR 'MP' EVENT TYPE, GO TO ST17 STDATEINTRO.
ELSE GO TO BOX ST17.
Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just
added.
IF AT LEAST ONE EVENT ADDED AT ST16 IS AN 'DU' OR 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS
NOT BEEN COLLECTED, GO TO ST18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18A - PROVSPEC.
ELSE GO TO BOX ST18.
What kind of medical person is (PROVIDER NAME)?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE
(03) AUDIOLOGIST
LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER
(04) CHIROPRACTOR
SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON
(05) CLINICAL SOCIAL WORKER
SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
OTHER MEDICAL PROVIDER (SPECIFY)
(01) CONTINUOUS ANSWER
What kind of dental provider is [PROVNAME]?
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIDONTIST
(41) PROSTHODONTIST
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
PROVSPECOTH

PROVSPECOTH

MR Screen Name
ST18A

Question type
code one

Question text/description
What kind of dental provider is [PROVNAME]?

ST18A
BOX ST18

verbatim text
routing

OTHER MEDICAL PROVIDER (SPECIFY)
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', 'IU', OR 'MP' EVENT TYPE) AND (SP
REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY PREVIOUS
ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ST19 - VAPLACE.

Code List
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(01) [Continuous answer.]

ELSE GO TO BOX ST19.
VAPLACE

ST19

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX ST19

routing

HMOASSOC

ST20

yes/no

HMOREFER

ST21

yes/no

NAVIGATOR

ST22A_IN

instance navigator

IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND (SP COVERED BY
A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED
WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 - HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND (SP
COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS PROVIDER IS
NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER.
ELSE GO TO ST22A_IN - NAVIGATOR.
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ITEM SELECTED IN INSTANCE NAVIGATOR BOX ST22A
(02) CONTINUE INTERVIEW SELECTED ST14 - STDATEUPD

Statement Charge Series (STQ)
Variable Name

MR Screen Name
BOX ST22A

Question type
routing

BOX ST22B

routing

ST23

yes/no

BOX ST23A

routing

EVENT_STDATE

BOX ST23B
ST24
BOX ST24

routing
roster
routing

RVLINKS

ST24A

numeric

BOX ST24A

routing

STDATEMTCH

ST25

code one

EVENT_STDATEDEL

ST26
BOX ST26

roster
routing

PROVIDER_STHH

ST27

roster

COSTBEGM

ST28

numeric

COSTBEGD

ST28

numeric

COSTBEGY

ST28

numeric

COSTENDM

ST28

numeric

COSTENDD

ST28

numeric

COSTENDY

ST28

numeric

BOX ST28A

routing

HHEVNTTYPE

ST30

code one

STHHINTRO

ST31

no entry

BOX ST31A

routing

MPSDVIS

Question text/description
FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B.
ELSE IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR.
ELSE GO TO BOX ST23B.
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE OVERLAPS AN EXISTING IP EVENT) OR
(EVENT DATE MATCHES AN EXISTING ER OR OP EVENT) GO TO ST23 - MPSDVIS.
ELSE GO TO BOX ST23A.
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW].
Was this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED
BELOW]/any of these places]?
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.
GO TO ST22A_IN - NAVIGATOR.
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS
CHARGE.
IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE ON (TYPE OF STATEMENT) SHOWN BELOW?

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 - PROVIDER_STHH.
ELSE GO TO BOX ST33.
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
ENTER THE START DATE AND STOP DATE COVERED BY THE CHARGE BUNDLE.
START DATE:

STOP DATE:

IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING PROVIDER WAS SELECTED AT ST27
THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE.
ELSE GO TO BOX ST31B.
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?
Before we continue with this statement, I would like to ask you a few questions about the home health
provider I just added.
IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.

Code List

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER
BOX ST31A

Statement Charge Series (STQ)
Variable Name

STHHMTCH

MR Screen Name
BOX ST31B

Question type
routing

ST32

code one

Question text/description
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO ST32 - STHHMTCH.
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.

BOX ST33

routing

ST34

code one

PLEASE USE THE BOX BELOW TO EXPLAIN IF THIS EVENT WAS ENTERED IN ERROR OR IF ANOTHER HOME
HEALTH EVENT SHOULD BE INCLUDED IN THIS CHARGE BUNDLE
IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.

ST35
ST36

roster
code one

DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

BOX ST36
ST37
BOX ST37

routing
roster
routing

MONTHCOV

ST38

numeric

MONCOV96

ST38

STOMUPD

EVENT_STOMEDIT
STOMADD

BOX ST38A

routing

BOX ST38B

routing

ST38A

numeric

BOX ST38AA

routing

STOMMTCH

ST39

code one

EVENT_STOMDEL

ST40
BOX ST40

roster
routing

EVENT_STPM

ST41

roster

NUMLINKS

ST42

grid

BOX ST42

routing

ST43

no entry

NUMLINKS

STPMINTRO

GO TO ST34 - STOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT).
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES
OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
SHOWN BELOW?
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM.
ELSE GO TO BOX ST45.
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
STATEMENT).
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE?

IF AT LEAST ONE PRESCRIPTION MEDICINE WAS ADDED AT ST41, GO TO ST43 - STPMINTRO.
ELSE GO TO ST44 - STPMMTCH.
Before we continue with this statement, I would like to ask you a few questions about the prescribed
medicine(s) I just added. [It would be very helpful for the following questions if we could look at the
bottle(s) or container(s) for the medicine(s).]

Code List

(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) GLASSES/CONTACTS
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
STPMMTCH

MR Screen Name
BOX ST43
ST44

Question type
routing
code one

Question text/description
GO TO ST44 - STPMMTCH.
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT) SHOWN
BELOW?

EVENT_STPMDEL

ST45

roster

SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

BOX ST45

routing

ST46

no entry

BOX ST46

routing

ST47

code one

BOX ST47

routing

TOTALCHG

ST47A

dollar

TOTALCHG

ST48

numeric

MCAPPAMT

ST48

numeric

MCPAYAMT

ST48

numeric

BOX ST48

routing

STTCHGPAID1

ST49

code one

CHANGAMT

ST50

yes/no

IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD,
GO TO ST46 - ORPMESSAGE.
ELSE GO TO BOX ST46.
SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD, WE DO NOT NEED ANY
CHARGE INFORMATION ABOUT THE BUNDLE.
IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR (TYPE OF STATEMENT = 4/Tricare AND
ST5 – STTTYPE = 4/Tricare) OR (ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE.
ELSE GO TO BOX ST47.
WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?
(01) YES
(02) NO
(03) CAN'T TELL
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)), GO TO ST47A - TOTALCHG.
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE =
4/Tricare) OR (TYPE OF STATEMENT = 6/TricareAndInsurance), GO TO ST48 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 - DAYSUSED.
ELSE GO TO ST60 - TOTALCHG.
ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE PRESCRIPTION DRUG BENEFIT STATEMENT. IF A
(01) CONTINUOUS ANSWER
TOTAL COST IS NOT LISTED, IT MAY BE NECESSARY TO CALCULATE A TOTAL BY ADDING THE COSTS OF
(-8) DON'T KNOW
INDIVIDUAL ITEMS LISTED ON THE STATEMENT.
(-9) REFUSED
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF AMOUNT NOT AVAILABLE, ENTER (01) CONTINUOUS ANSWER
"DON'T KNOW".
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51.
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK OR RF) AND (AMOUNT REMAINING <
.02 * ST48 - MCAPPAMT)), GO TO BOX ST80.
ELSE GO TO ST49 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE (01) SP OR ANY SOURCE PAID
SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(02) NOTHING HAS BEEN PAID
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] (03) AMOUNT REMAINING SEEMS WRONG
or any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
(-8) DON'T KNOW
amount?
(-9) REFUSED
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) STATEMENT:
(01) YES
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
(02) NO

ORPMESSAGE

ASGNTAKE

Code List
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) CONTINUOUS ANSWER

TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)

TOTALCHG

ST51

numeric

AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
MCAPPAMT

MR Screen Name
ST51

Question type
numeric

MCPAYAMT

ST51

numeric

BOX ST51

routing

TOTALCHG

ST52

numeric

MCAPPAMT

ST52

numeric

MCPAYAMT

ST52

numeric

MAYBBILL

ST52

numeric

STTCHGPAID1

ST53

code one

CHANGAMT

ST54

yes/no

Question text/description

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND ((AMOUNT REMAINING <
$1.00) OR ((ST51 - MCAPPAMT ^= DK AND ST51 - MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 *
ST51 - MCAPPAMT))), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:

REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)]
or any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)

Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO

MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
MEDICARE PAID: (MEDICARE PAYMENT)

TOTALCHG

ST55

numeric

MCAPPAMT

ST55

numeric

MCPAYAMT

ST55

numeric

MAYBBILL

ST55

numeric

BOX ST55

routing

DAYSUSED

ST56

numeric

NONCOVRD

ST56

numeric

MCPAYAMT

ST56

numeric

MAYBBILL

ST56

numeric

YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

Statement Charge Series (STQ)
Variable Name

MR Screen Name
BOX ST56

Question type
routing

STTCHGPAID1

ST57

code one

CHANGAMT

ST58

yes/no

Question text/description
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST57 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE
SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?
THESE AMOUNTS WERE ENTERED FROM THE MSN:
BENEFITS DAYS USED: (DAYS USED)

Code List

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO

NON-COVERED CHARGES: (NON COVERED CHARGES)
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

DAYSUSED

ST59

numeric

NONCOVRD

ST59

numeric

MCPAYAMT

ST59

numeric

MAYBBILL

ST59

numeric

BOX ST59

routing

TOTALCHG

ST60

numeric

MCAPPAMT

ST60

numeric

MCPAYAMT

ST60

numeric

MAYBBILL

ST60

numeric

BOX ST60

STTCHGPAID1

ST61

code one

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST61 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE
SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining (AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
CHANGAMT

MR Screen Name
ST62

Question type
yes/no

Question text/description
THESE AMOUNTS WERE ENTERED FROM THE MSN:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)

Code List
(01) YES
(02) NO

MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

TOTALCHG

ST63

numeric

MCAPPAMT

ST63

numeric

MCPAYAMT

ST63

numeric

MAYBBILL

ST63

numeric

BOX ST63

routing

ST64

code one

BOX ST64A

routing

BOX ST64B

routing

STADDSOP1

ST65

yes/no

SOP_ST1
TSOPAMT

ST66
ST67

roster
grid

BOX ST67HE

routing

ST67HE

no entry

BOXST67A

routing

BOX ST67B

routing

STTCHGPAID2

PAYMHE

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE
SO. POINT OUT (PROVIDER NAME), DATE(S), AND TYPE OF SERVICE(S). (THEN ASK:/SELECT "SP OR ANY
SOURCE PAID" IF ALREADY KNOWN. OTHERWISE ASK:)
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE TEXT).] [[Have you/Has
(SP)]/Besides Medicare, [have you/has (SP)]] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid anything for this?
IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID), GO
TO BOX ST78B.
ELSE GO TO BOX ST80.
CREATE SOURCE OF PAYMENT ROSTER
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES ENTERED IN ST SECTION) AND (ST65 –
STADDSOP1 HAS BEEN ASKED IN THE CURRENT ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT ST67),
GO TO ST67 - TSOPAMT.
ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR COMPLETING THE STATEMENT SECTION LISTED
BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
ADD ALL ADDITIONAL SOURCES OF PAYMENT.
(REFER TO INSURANCE STATEMENT/REFER TO TRICARE STATEMENT/REFER TO INSURANCE AND TRICARE
STATEMENTS/REFER TO MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT).
Who (else) paid besides Medicare? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A.
ELSE GO TO ST67HE - PAYMHE.
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER THAN $0.00 OR AT LEAST ONE PAYMENT
AMOUNT MUST BE 'DON'T KNOW' OR 'REFUSED'.
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE CORRECTIONS.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO BOX ST67B.
ELSE GO TO BOX ST69F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH INSURANCE PLAN, GO TO ST67BINT PLANINTRO. ELSE GO TO BOX ST69E.

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER

Statement Charge Series (STQ)
Variable Name
PLANINTRO

MR Screen Name
ST67BINT

Question type
no entry

NAVIGATOR

ST67B_IN

instance navigator

BOX ST67C

routing

STMHMOCHNG1

ST68

yes/no

STSOPCURR1

ST69

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

STMPDPCHNG

ST69A

yes/no

I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.

STSOPCURR2

AMTSCORR

ST69B

yes/no

BOX ST69A
BOX ST69E

routing
routing

BOX ST69F

routing

ST70

code one

Question text/description
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just
added.

Code List
(01) CONTINUOUS ANSWER
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT ST66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE
PLAN THAT IS CURRENT, GO TO ST68 - STMHMOCHNG1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A MEDICARE
MANAGED CARE PLAN THAT IS CURRENT, GO TO ST69 - STSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69A - STMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A
MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69B - STSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
Medicare Managed Care Plan. Has this information changed?

Has this information changed?
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

GO TO ST67B_IN - NAVIGATOR.
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT
ADDED AT ST66 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX ST69F.
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)) and ((TOTAL CHARGE ^= DK and TOTAL CHARGE ^= RF) and (ALL PAYMENTS
ENTERED AT ST67 ^= DK AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT ST67) AND
(THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL PAYMENTS ENTERED AT ST67 IS > $1.00)), GO TO
ST73 - AMTSCORR.
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AT LEAST ONE PAYMENT
ENTERED AT ST67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT ST67 IS >= AMOUNT REMAINING), GO TO ST71 AMTSCORR.
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (ALL PAYMENTS ENTERED
AT ST67 ^= DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL
PAYMENTS ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00), GO TO ST70 - AMTSCORR.
ELSE GO TO BOX ST77C.
There seems to be (some amount still unpaid/more payments than the amount left after Medicare paid).
The total of non-Medicare payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid) is
$(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP
GRID.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) ENTRIES ABOVE ARE CORRECT
(02) DO NOT DISPLAY
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED

Statement Charge Series (STQ)
Variable Name
AMTSCORR

MR Screen Name
ST71

Question type
code one

Question text/description
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE (TOTAL
CHARGE/AMOUNT REMAINING), WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL
AMOUNTS AS ENTERED.

ENTERCOM

ST72

no entry

[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT (UNPAID/OVERPAID) IS (01) CONTINUOUS ANSWER
$(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING).]

AMTSCORR

ST73

yes/no

INFOEXPLAIN

ST74

yes/no

ENTERCOM2

ST75
BOX ST77C

no entry
routing

BOX ST77D

routing

ST78

Code List
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP (-8)
GRID.
(-9) REFUSED

USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
There seems to be some amount still unpaid. The total of non-Medicare payments is $(TOTAL PAYMENTS).
The amount unpaid is $(DIFFERENCE BETWEEN TOTAL CHARGE AND PAYMENTS). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP
GRID.

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT DO NOT
DISPLAY.
(-8)
(-9) REFUSED

IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT STATEMENT THAT EXPLAINS THE AMOUNT
STILL UNPAID?
USE THE BOX BELOW TO ENTER ANY INFORMATION THAT EXPLAINS THE AMOUNT STILL UNPAID.
CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67
GO TO BOX ST77D.
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO ST78 - EXPPAYBK.
ELSE GO TO BOX ST80.

(01) YES
(02) NO

yes/no

I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX ST78A

routing

BOX ST78B

routing

EXPAYOUT

ST79

yes/no

EXPAYUNT

ST80

quantity unit

EXPAYPCT
EXPAYAMT

ST80
ST80
BOX ST80

numeric
numeric
routing

ABUNDLE

ST81

yes/no

IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED
2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE AND ROUND IS NOT 71)), GO TO
ST80 - EXPAYUNT.
ELSE GO TO BOX ST80.
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE AND ROUND IS NOT 71)), GO TO ST79 - EXPAYOUT.
ELSE GO TO BOX ST80.
Do you expect anyone to pay any of this amount?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
How much do you expect will be paid?
(01) PERCENTAGE
(02) DOLLARS
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG.
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)), GO TO ST82 - ASTATEMENT.
ELSE GO TO ST81 - ABUNDLE.
IS THERE ANOTHER CHARGE BUNDLE TO ENTER FROM THIS (TYPE OF STATEMENT)?
(01) YES
(02) NO

ASTATEMENT

ST82

yes/no

BOX STEND

routing

EXPPAYBK

IS THERE ANOTHER MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT
TO ENTER?
GO TO NEXT SECTION.

(01) YES
(02) NO